| Entity Name: | BREVARD PSYCHOLOGICAL ASSOCIATES, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 20 Jan 2015 (10 years ago) |
| Date of dissolution: | 27 Sep 2019 (5 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 27 Sep 2019 (5 years ago) |
| Document Number: | P15000005821 |
| FEI/EIN Number | 47-2782781 |
| Address: | 1611 SOUTH APOLLO BLVD, MELBOURNE, FL, 32901 |
| Mail Address: | 1611 SOUTH APOLLO BLVD, MELBOURNE, FL, 32901 |
| ZIP code: | 32901 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1518351824 | 2015-03-25 | 2015-03-25 | 1611 SOUTH APOLLO BLVD., MELBOURNE, FL, 32901, US | 1611 S APOLLO BLVD, MELBOURNE, FL, 329014407, US | |||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||
| Phone | +1 321-724-2444 |
| Fax | 3219524131 |
Authorized person
| Name | DR. TIMOTHY C SHORT, PSY. D |
| Role | OWNER |
| Phone | 3217242444 |
Taxonomy
| Taxonomy Code | 103TC1900X - Counseling Psychologist |
| License Number | PY4790 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | WORKERS COMPENSATION |
| Number | 611051700 |
| State | FL |
| Issuer | BLUE CROSS BLUE SHIELT OF FLORIDA |
| Number | 59348 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SHORT TIMOTHY | Agent | 1611 SOUTH APOLLO BLVD, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| SHORT TIMOTHY C | President | 1611 SOUTH APOLLO BLVD, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| SHORT TIMOTHY C | Director | 1611 SOUTH APOLLO BLVD, MELBOURNE, FL, 32901 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2019-09-27 | No data | No data |
| AMENDMENT AND NAME CHANGE | 2015-02-03 | BREVARD PSYCHOLOGICAL ASSOCIATES, INC. | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2018-03-04 |
| ANNUAL REPORT | 2017-03-28 |
| ANNUAL REPORT | 2016-02-10 |
| Amendment and Name Change | 2015-02-03 |
| Domestic Profit | 2015-01-20 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
